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ER8 Emergency Medicine
Traumatology Toronto Notes 2019
Warning Signs of Severe Head Injury
• GCS <8
• Deteriorating GCS
• Unequal pupils
• Lateralizing signs
N.B. Altered LOC is a hallmark of brain injury
Canadian CT Head Rule
Lancet 2001;357:1391-96
CT Head is only required for patients with minor HI with any one of the following High Risk (for neurological intervention)
• GCS score <15 at 2 h after injury
• scalplaceration
■ can be a source of significant bleeding
■ achieve hemostasis, inspect and palpate for skull bone defects ± CT head (rule-out skull fracture)
• neuronalinjury
A. diffuse
■ mild TBI = concussion
◆ transient alteration in mental status that may involve loss of consciousness
◆ hallmarks of concussion: confusion and amnesia, which may occur immediately after the
trauma or minutes later
◆ loss of consciousness (if present) must be less than 30 min, initial GCS must be between 13-15,
and post-traumatic amnesia must be less than 24 h ■ diffuse axonal injury
◆ mild: coma 6-24 h, possibly lasting deficit
◆ moderate: coma >24 h, little or no signs of brainstem dysfunction ◆ severe: coma >24 h, frequent signs of brainstem dysfunction
B. focal injuries
■ contusions
■ intracranial hemorrhage (epidural, subdural, intracerebral)
ASSESSMENT OF BRAIN INJURY
History
• pre-hospitalstatus
• mechanismofinjury
Physical Exam
• assumeC-spineinjuryuntilruledout • vitalsigns
■ shock (not likely due to isolated brain injury, except in infants)
■ Cushing’s response to increasing ICP (bradycardia, HTN, irregular respirations) • severityofinjurydeterminedby
1. LOC
◆ GCS ≤8 intubate, any change in score of 3 or more = serious injury ◆ mild TBI = 13-15, moderate = 9-12, severe = 3-8
2. pupils: size, anisocoria >1 mm (in patient with altered LOC), response to light 3. lateralizing signs (motor/sensory)
◆ may become subtler with increasing severity of injury ◆ reassess frequently
Investigations
• labs:CBC,electrolytes,INR/PTT,glucose,toxicologyscreen
• CTscanheadandneck(non-contrast)toexcludeintracranialhemorrhage/hematoma • C-spineimaging
Management
• goalinED:reducesecondaryinjurybyavoidinghypoxia,ischemia,decreasedCPP,seizure • general
■ ABCs
■ ensure oxygen delivery to brain through intubation and prevent hypercarbia ■ maintainBP(sBP>90)
■ treat other injuries
• earlyneurosurgicalconsultationforacuteandsubsequentpatientmanagement • seizure treatment/prophylaxis
■ benzodiazepines, phenytoin, phenobarbital
■ steroids are of no proven value
• treat suspected raised ICP, consider if HI with signs of increased ICP:
■ intubate
■ calm (sedate) if risk for high airway pressures or agitation
■ paralyze if agitated
■ hyperventilate (100% O2) to a pCO2 of 30-35 mmHg
■ elevate head of bed to 20o
■ adequate BP to ensure good cerebral perfusion
■ diurese with mannitol 1g/kg infused rapidly (contraindicated in shock/renal failure)
Disposition
• neurosurgicalICUadmissionforsevereHI
• inhemodynamicallyunstablepatientwithotherinjuries,prioritizemostlife-threateninginjuriesand
maintain cerebral perfusion
• forminorHInotrequiringadmission,provide24hHIprotocoltocompetentcaregiver,follow-upwith
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture
(hemotympanum, “raccoon” eyes, CSF
otorrhea/rhinorrhea, Battle’s sign)
• Vomiting ≥2 episodes
• Age ≥65 yr
Medium Risk (for brain injury on CT)
• Amnesia before impact >30 min (i.e.
cannot recall events just before impact)
• Dangerous mechanism (pedestrian struck by MVC, occupant ejected from motor
vehicle, fall from height >3 ft or five stairs) Minor HI is defined as witnessed loss
of consciousness, definite amnesia, or witnessed disorientation in a patient with a GCS score of 13-15.
NB: Canadian CT Head Rule does not apply for non- trauma cases, for GCS<13, age <16, for patients
on Coumadin® and/or having a bleeding disorder, or having an obvious open skull fracture.
neurology as even seemingly minor HI may cause lasting deficits